Original Article

Development of a sustainable community

mental health program in a remote region:
the Austral Institute for Mental Health
Desenvolvimento de um programa sustentável de saúde mental
comunitária numa região remota: o Instituto Austral de Saúde Mental
Jose Lumerman1, Sarah Conover2

Abstract
This paper described a community-based rehabilitation program in a remote region of Argentina. The program is located in
Neuquén Province, in the Patagonia region. At the time it was initiated, about 20 years ago, the province had an excellent
system of primary care, but one in which mental disorders were neglected. There were only a few psychiatrists in the province,
and none involved in community care of people with severe mental disorders. Starting from this point, the “Austral” program
was developed by making use of the local resources (such as primary care doctors) that were available, and it later earned
a reputation as a model program. In 2012, Neuquén became a site of the RedeAmericas, a National Institute of Mental Health
funded regional mental health network in Latin America.
Keywords: Community Health Services; global health; mental health services; sustainable development indicators.

Resumo
Este artigo descreveu um programa comunitário de reabilitação baseado em uma região remota da Argentina. O mesmo está
localizado na Província de Neuquén, na Patagônia. No momento em que foi iniciado, há aproximadamente 20 anos, tinha um
excelente sistema de cuidados de saúde primários, mas no qual os transtornos mentais foram negligenciados. Havia apenas
alguns psiquiatras na província, e nenhum estava envolvido com atendimento comunitário para pessoas com transtornos
mentais graves. A partir desse ponto, o programa “Austral” desenvolveu-se por meio da utilização dos recursos locais (como
os médicos de cuidados primários) que estavam disponíveis, e com o tempo ganhou reputação de programa modelo.
Em 2012, Neuquén tornou-se sede da RedeAmericas, uma rede regional de saúde mental da América Latina financiada pelo
governo dos Estados Unidos.
Palavras-chave: Serviços de Saúde Comunitária; saúde mundial; serviços de saúde mental; indicadores de desenvolvi-
mento sustentável.

Study carried out at Instituto Austral de Salud Mental – Neuquén, Argentina.

1
Psychiatrist; General Director and Founder of the Instituto Austral de Salud Mental – Neuquén, Argentina.
2
Epidemiologist; Co-director of the CTI Global Network, Silberman School of Social Work at Hunter College – New York City, NY, USA.
Mailing address: Jose Lumerman – Instituto Austral de Salud Mental – Belgrano 76, Neuquén 8300, Argentina, 0054-28844305 – E-mail: joselumerman@gmail.com
Financial support: none.
Conflict of interest: nothing to declare.

80 Cad. Saúde Colet., 2013, Rio de Janeiro, 21 (1): 80-4


INTRODUCTION
This paper describes a community-based rehabilitation
program in the province of Neuquén, in the remote Patagonia
region of Argentina, which has been sustained for 20 years.
Previous publications have described the early phase of
the program1,2, but this is the first description of how it has
evolved and been maintained over such a long period. It is
now recognized worldwide as a model program, cited by the
World Health Organization Mental Health Division3 and by
the World Federation for Mental Health4. Numerous trainees
from other places, including the United States and Europe,
take electives during which they learn about the program and
participate in its work.
One of the authors of this paper was the originator of the
program and continues to lead it; and the other was one of
three founding members of a group of international consul-
tants who have helped support and shape its development
since its initiation. Five members of this group are now also
involved in RedeAmericas. Pamela Collins is no longer in-
volved with the Austral, due to the potential for conflict of in-
terest; as a leader in the field of global mental health, she now
plays a key role in the development of global mental health
initiatives such as RedeAmericas within the National Institute
of Mental Health (NIMH)5.
CONTEXT
The province of Neuquén is vast, bounded by two riv-
ers fed by the melting snows of the Andes mountain range.
It forms a triangle in the Northwest of the Argentinian
Patagonia. Neuquén was “national territory” until 1956, when
it became a province of the Argentinian Republic. The new
one was extremely rich in natural resources, for example, it
had major oil and gas fields, large areas of fertile land, and
other of dense native jungle. It also had a natural beauty that
now attracts tourists from around the world.
Nonetheless, in its early decades, many communities were
very poor and a significant number of people was destitute. The
population was comprised mainly of indigenous communities,
and recent migrants from other Argentinean provinces and
neighboring countries who came in search of work. The major-
ity of the population was children and youth. Such population
was afflicted by high rates of childhood malnutrition, endemic
illnesses like hydatidosis and tuberculosis, and one of the high-
est infant mortality rates in the Americas (more than one in ten
babies). This poor state of population health reflected in part the
almost complete absence of a provincial public health program.
By the late 1960s, migrants had become a larger propor-
tion of the population, especially in the city of Neuquén, and
Sustainable community mental health program in a remote region
the standard of living had improved in many communities
as the natural resources were exploited, generating jobs and
income. Nonetheless, there had not been a commensurate im-
provement in population health, for example, infant mortality
rates remained very high. At this time, Governor Don Felipe
Sapag, responding to demands from mothers to improve
child’s health, initiated the development of a remarkably in-
novative public health policy. At the heart of the policy was
a universally accessible health care system based on primary
care, which was delivered by general doctors, nurses, and
paraprofessionals within each local community. Secondary
and tertiary cares were available at district level on referral.
Within a decade, the health system and other public health
policies had been rapidly transformed. The province had de-
veloped an integrated health care system, making use of local
resources, under the leadership of cutting edge public health pro-
fessionals such as Doctors Moreno and Perrone. This in turn was
a major contributor to a transformation in population’s health.
The infant mortality rate has continued to decline. For example,
over the 30-year period from 1980  to 2009, the rate dropped
from 31.7 to 7.6%6. The degree and rapidity of this improvement
in public health is unparalleled in the history of Argentina.
Over subsequent years, the health system was further de-
veloped and consolidated. It achieved virtual self-sufficiency,
that is, it was rarely necessary to refer patients to health care
outside the province, with one notable exception. The excep-
tion was mental health care, which had not been integrated
into the public health system of the province.
MENTAL HEALTH CARE IN NEUQUÉN BEFORE
THE AUSTRAL
In 1987, the public mental health system of the province
was essentially limited to nine psychiatric beds in a tertiary care
hospital (Castro Rendon Hospital) for the entire population of
400,000 inhabitants. Outpatient care was mainly provided by a
few office-based specialists in the private sector in the capital
city of Neuquén. Jose Lumerman was recruited to Neuquén to
work in the public health system, with the mission of chang-
ing this situation. It proved difficult to do so due to changes in
leadership and general resistance to inclusion of mental health
services as a major component.
In 1993, aware of the gap in mental health services in
the public sector, the medical director of Neuquén’s Social
Security Institute (ISSN) asked JL to develop a nongovern-
mental organization for the care of ISSN members with se-
vere mental disorders. ISSN is a form of social insurance that
represents the most important source of funding for health
services for most of the population.
Cad. Saúde Colet., 2013, Rio de Janeiro, 21 (1): 80-4 81
 Jose Lumerman, Sarah Conover
Until that time, most patients with severe mental disor-
ders had to be transferred to Buenos Aires (more than a thou-
sand miles away) for specialized care. For those who were not
wealthy, this often meant inpatient care in La Borda, a large
and crowded asylum in Buenos Aires. It is not known how
many people never returned to Neuquén. Those who did re-
ceived minimal if any follow-up care; many relapsed and were
sent back to Buenos Aires for re-hospitalization. This gener-
ated high costs for the ISSN, as well as unsatisfactory clinical
outcomes for the affected individuals and their families.
CREATION OF THE AUSTRAL INSTITUTE OF
MENTAL HEALTH
The challenge that JL confronted was to develop a pro-
gram for mental health care in a province that had virtually
no psychiatrists providing care for people with severe mental
disorders. Furthermore, the program had to be established
outside the provincial public health system, though it would
also need to maintain strong ties with that system. His previ-
ous experience in the public health system of the province en-
abled him, however, to identify other kinds of local resources,
and to envision a community based mental health care that
could be built with these resources. Clearly, primary care
teams consisting of general practitioners, nurses, social work-
ers and community health workers were providing adequate
care for people with chronic diseases such as diabetes. Why
could they not do the same for people affected by chronic
psychiatric disorders? At the same time, other kinds of local
resources were potentially available to fulfill the roles usually
played by occupational therapists and others in psychiatric
rehabilitation. Why not use artists, dancers, actors, authors,
and sculptors?
The Austral Institute was developed as a novel approach
to the use of these local resources for community mental
health care. A central guiding concept since the initiation of
the program has been “alta simplicidad” (high simplicity, in
English). This meant the distillation of complex concepts of
care into basic principles that could be conveyed to all stake-
holders in the community, including service users, their fami-
lies, journalists, policy makers, teachers, judges, and others.
Indeed, it was apparent from the start that for the program
to be sustained, it would need to be understandable to the
entire community. Alta simplicidad also defined the elabora-
tion of corresponding mental health care practices that could
be implemented by nonspecialist workers, an approach that
nowadays would be considered as a form of “task shifting”.
Following this principle, the new Institute used teams led
by general practitioners who learned to recognize the basic
82 Cad. Saúde Colet., 2013, Rio de Janeiro, 21 (1): 80-4
symptoms of mental disorders, and the appropriate treat-
ment. Treatment included the key elements of the healing
process: outreach and support delivered at home and/or at a
welcoming locale (the Institute); support for family members;
a recovery orientation (in current terminology); advocacy in
the community to allow patients to participate in civic life;
and medications.
SERVICES OF THE AUSTRAL INSTITUTE
The program has evolved a great deal, and now includes
nurses, psychologists, and other mental health professionals.
Nonetheless, the central elements of the team structure have
remained in place. For example, the general practitioner is the
overall team leader and monitors physical health and medica-
tions as well. The community mental health worker spends
more time than other members of the team providing services
to the patient and family and has the most intimate knowledge
of their circumstances. A psychiatrist is available for consulta-
tion. The team meets regularly to share experiences and plan
treatment strategies.
Over a period of about 20 years, in conjunction with this
general approach, a wide spectrum of outpatient services were
developed. We describe three of them briefly here; others, not
described, include services for children.
The Day Hospital is the highest intensity outpatient
service. For the creation of the Day Hospital, a comfortable
house was chosen in the center of the city of Neuquén, and
renovated by a local architect, to provide an open and cozy
space. In its center, there is a prominent kitchen run by a chef
who cooks delicious meals and interacts with patients. For
patients in a state of crisis who cannot manage with the Day
Hospital alone, there is also intensive home care which helps
prevent the need for hospitalization. In addition, all patients
receive home visits as part of assessment and ongoing work.
Patients are assessed and monitored by their general practi-
tioner and have psychiatric consultations. They participate in
“Basic Needs and Functioning” groups, in groups for plan-
ning the weekends, in recreation workshops, and in multi-
family meetings, usually led by the community mental health
workers. They also discuss ways to socialize and participate in
the broader Neuquén community during their free time, both
in one to one meetings with staff and in the various groups.
The average length of stay in the Day Hospital is four months.
The Half-Day Hospital is a service of medium intensity
where patients are offered therapeutic activities similar to
those of the Day Hospital, but less intensive, and with more
emphasis on groups. Often patients move from the Day
Hospital to the Half-Day Hospital as they improve, but they

can also start in the Half-day Hospital, depending on their
condition and needs. The average stay is three months.
A third key component service is rehabilitation. Although
rehabilitation was always central to the mission of the Austral,
the services available have increased gradually over time,
and especially in the last few years. The rehabilitation pro-
cess begins in the Day Hospital, continues in the Half-Day
Hospital, and finally becomes the main type of activity. Key
to the rehabilitation process are the groups run by artists and
agricultural technicians and other non-mental health profes-
sionals. These groups take place out in the community with
the support of the community mental health workers of the
Austral. Recently patients from the Austral have been admit-
ted to courses in agricultural methods that are offered by the
Province to the entire community. They participate as regular
trainees, with no distinction made between Austral referrals
and other trainees. Also, patients have set up various kinds
of small businesses (e.g., making crafts out of wood to sell at
the artisan fair on weekends), initially with the assistance of
Austral staff, and later becoming virtually independent (staff
still visit and offer some practical help when needed). There is
no specified time limit to the rehabilitation process.
Since its creation, the Austral has treated over 5,000 pa-
tients and their families. Very few have required hospitaliza-
tion. Following treatment, the great majority has been able to
live in decent accommodation in the community, and have
maintained enduring ties with their families. Often a family
was initially disconnected from, or critical of a patient, and/or
vice versa, but over time the family became a solid and wel-
come source of support. Many former patients have obtained
employment. Thus, Neuquén has been transformed from a
province in which community mental health issues were largely
ignored into a province where people with mental disorders
receive adequate help.
SUSTAINABILITY OF THE MODEL
Although there are many models of “task shifting” in
global mental health, some distinctive features differentiate
the Austral program from other models. We have already
described one, that is, the reliance on general doctors as team
leaders. The most distinctive (and possibly unique) feature,
however, is that it has been maintained for nearly 20 years,
in a remote area of a middle income country. We think there
were three key factors that contributed to its sustainability.
The first factor is the strength of the relationship with
stakeholders in the community. This has been achieved
by ongoing efforts to maintain the ties of the Austral to
a wide range of groups, such as government sectors and
Sustainable community mental health program in a remote region
community groups and media. The government sectors
alone include health, education, social security and justice.
An enormous amount of time and energy has been devoted
to these relationships, some of which are inherently unsta-
ble, for example, the periodic change of the political party
in control of the provincial government always requires
some reshaping of relationships.
The second factor is internal to the Austral itself, that is,
the continuity of people who contribute to the institute in
general, and the continuity of the Austral team in particular.
“Continuity” does not mean constancy, but rather, that turn-
over of staff is gradual, so that a core with experience remains;
new staff can be introduced and trained as replacements or
to lead the extension of services. This continuity is owed in
part to the way the program was designed. Each team mem-
ber’s contribution is recognized as important in the team
meetings where the evolution of the patients and families in
the various therapeutic areas is discussed. Team members
are encouraged to develop and  increase their responsibili-
ties, and further, to propose new initiatives. Furthermore,
the team shares a commitment to the approach used, and
above all, to the overall wellbeing of patients and  families.
These and other factors help foster enthusiasm and initia-
tive, and thus prevent “burn-out”.
The third factor is its ongoing relationship with interna-
tional advisors in psychiatry, epidemiology and community
mental health, who have made periodic visits to provide train-
ing. As noted earlier, one of the authors was intimately involved
throughout this process from the beginning. The involvement
of international advisors turned out to be important to sus-
tainability for several reasons. First, it had a positive impact on
morale of both staff and patients. International advisors who
met with both staff and patients, and were impressed by the
work being done, offered a kind of validation that something
important was being achieved. Second, international advi-
sors could provide guidance in some areas where expertise
was lacking, and connect the Austral to related work being
done across other regions of the globe. Third, their ongoing
involvement led to international friendships that still help
maintain morale, partly through direct contact, and partly
through trainees, as described later. Fourth, it helped to raise
the prestige of the work in the eyes of various stakeholders,
such as government agencies. Fifth, it facilitated access to lo-
cal and national media, which helped to disseminate the work
of a program in a remote province to a broad audience across
the country, and to some extent, to other countries. Finally, it
created the potential to do research to gauge the effectiveness
of the program in a rigorous way, although this potential is
not yet fully realized.
Cad. Saúde Colet., 2013, Rio de Janeiro, 21 (1): 80-4 83
 Jose Lumerman, Sarah Conover
RECIPROCITY
It would be very misleading to represent the interaction with the
international advisors as a one-way process. In fact, our impression
is that the international advisors learned as much from the Austral
as vice versa. Many people who later became prominent in what
is now called “global mental health” were part of the international
advisory team of the Austral at a formative stage in their careers.
Three examples are Pamela Collins, Graham Thornicroft, and
Ezra Susser, each of whom had longstanding relationships with the
Austral. These advisors participated not only in the development of
the Austral per se, described here, but also in province-wide efforts
to introduce mental health care into routine practice in the primary
care system of the province. They were profoundly influenced by
these experiences, and drew upon it in their subsequent work.
Furthermore, the Austral has served as a “practicum” ex-
perience for students in high-income countries to learn about
the possibilities and challenges for mental health programs in
a remote area of a middle-income country. The staff and pa-
tients alike have warmly welcomed trainees from the United
States, the United Kingdom, the Netherlands, and other
countries. At present, approximately 50 trainees have had this
experience, and the number continues to grow. They include
young psychiatrists, other mental health and public health
trainees, medical students, and motivated undergraduates.
CONCLUSIONS
The experience of the Austral suggests that good
community mental health care is feasible and sustainable
References
1. Susser E, Rojas G, Alvarado R, Galea S. RedeAmericas: Network for
Mental Health Research in the Americas, an Introduction. Cad Saúde
Colet. 2012;20(4):403-4.
2. Collins PY, Adler FW, Boero M, Susser E. Using local resources in
Patagonia: Primary care and mental health in Neuquén, Argentina. Int J
Ment Health. 1999;28(3):3-16.
3. World Health Organization (WHO) and World Organization of Family
Doctors (Wonca). Physician-led primary care for mental health in
Neuquén province, Patagonia region. In: Integrating mental health into
primary health care: a global perspective. Geneva WHO Press; 2008, 57 p.
4. World Federation for Mental Health. Integrating mental health into
primary care – primary care for mental health in practice.  In:  Mental
84 Cad. Saúde Colet., 2013, Rio de Janeiro, 21 (1): 80-4
in remote settings in middle income countries where
there are few psychiatrists and few psychiatric inpatient
beds. The program has also had a broad impact on the
region  that goes beyond the individual patient care pro-
vided. Through its alliances with media and other sectors,
mental health has become a theme of interest for the peo-
ple in general, and for policy makers in particular, which
is of crucial importance for the struggle against stigma
and for increased investment in mental health services.
As a result of related work with primary care doctors in
the province, mental health has gradually become part of
routine primary care and of medical training. In this con-
text, the Austral has become a center of training for doc-
tors, psychologists, nurses, social workers and advanced
students who later assume positions in the primary care
system of the province. Also, some of the former general
doctors of the Austral are now key figures in the Neuquén
Ministry of Health, where they facilitate the integration
of mental health into primary care. Thus, one small pro-
gram in a remote province has over the long term had a
profound impact within the province, as well as an ap-
preciable impact across the globe. Now, as one of the sites
of RedeAmericas, we expect that the influence  of the
program across Latin America will grow, and at the same
time, that the program will introduce new ideas from
other sites of RedeAmericas. Being part of RedeAmericas
may also allow for a full evaluation to document how the
program influences the lives of the patients it serves, and
to examine in more depth the reasons for its sustainability.
health in primary care: enhancing treatment and promoting mental health.
Woodbridge World Federation for Mental Health; 2009, p. 11-3.
5. Collins PY, Patel V, Joestl SS, March D, Insel TR, Daar AS, et al. Grand
challenges in global mental health. Nature. 2011;475(7354):27-30.
6. Ministerio de Economía y Obras Públicas, Dirección Provincial de
Estadística y Censos. Estadísticas Vitales y Medidas Demográficas Básicas
(1980/2009). Provincia del Neuquén [Internet]. Tasa de mortalidad
infantil, neonatal y postneonatal de residentes según año, Provincia del
Neuquén, 1980-2009 [cited June 2012]. Available from: http://www3.
neuquen.gov.ar/dgecyd/Publicaciones/Vitales/Vitales1980-2009.pdf
Received on: 10/16/2012
Accepted on: 01/21/2013